Archive for November 2009
My two preceptors happened to both be on the same day and I got to hear them discuss with each other how they think I am doing in my orientation. I am slowly catching on to the flow of the department. I can take care of two to three patients at a time by myself as long as there is nothing to unusual going on. I can usually get an IV in on the first try but not always, I know the codes to get in the med room and the psych unit. When someone needs me to get something for them not only do I know what the thing is and what it looks like, I can usually find it. I am still rather slow and methodical, I still take longer to chart as I ponder the wording of my nurses notes. But for the most part they think I am doing fine. One preceptor said to the other, “you know she is going to be fine because she has the maturity to not freak out about what happens, and she is a mom so you know she can multitask!” The one thing they both remind me about is the fact that in the ER we can’t fix all of peoples problems. Many of our patients have chronic issues and psych social problems that are not solved quickly if at all. I had a patient in for back pain needing a refill of her RX however she had several other issues that we could have helped her with but didn’t. She was a diabetic and her finger stick glucose machine was not working properly, she needed a new one, she had a nasty contact dermatitis on her abdomen that could have used some barrier cream and perhaps steroid cream, and she had a decubitus ulcer developing on her hand where it was contracted due to a stroke 3 years earlier. She was feeling overwhelmed and frustrated with staying on top of her own care, and I felt like we could have taken an extra 15-30 min to just help her out and get her back on track. However the ER doc insisted that she follow up with her primary care doc for those things and just refilled her pain med RX, even when I asked him about it. We had a homeless guy found under the overpass in a drunken stupor, we rehydrated him, got him a spot in a detox center because he said he wanted to go and heard that the next day he was thrown out. Then there was the mom and her two kids, she told triage that she was having asthma problems, but when I interviewed her she told me she needed a document from our ER for her employer excusing her from work for a car accident that happened 4 months ago! oh, and also her daughter had a cough and a slight fever. She was going to lose her job if she didn’t produce this note, but we couldn’t help her, it was 4 months ago and she didn’t seek treatment! Lots and lots of smokers and alcoholics who are coming in with health issues that are either due to the habits or made worse by those habits. I can’t fix them, I can just help them with their problem of the moment. I can be compassionate, and listen to them, and try not to make them feel like they are just another chart to be checked off and pushed through. The motto for the ER is “treat ’em and street ’em” and sometimes “admit ’em”. I just need to learn how far to go with each of them, where does the ER care end and another resource pick up and can I make sure they get connected with that other resource to help them with those chronic issues that take longer to remedy. It is a fine line, and I seem to run right over it resulting in my precepter stepping in to say “you need to ask the doc what the plan is for your pt, we have done what we can” That line always comes sooner than I want it. I have so much to learn.
Each week of orientation we are supposed to work towards some goals. They start out pretty basic such as find various supplies in the unit, identify where the medication resources are, care for one patient from arrival to discharge. I have two preceptors that I am working with, both wonderful nurses but with very different styles. This is a good thing for me as it gives me the perspective that there is more than one way to do things. One of my preceptors is also a nursing instructor at one of the local colleges so she is very much into writing out my goals and how well I accomplish them each shift. At the end of the shifts though, the last thing I want to do is organize what happened into a list of goals fulfilled! But I try. I am getting to the end of week four in my training and my goals are a little harder to reach. This week I am supposed to care for respiratory and cardiac patients, take two patients with increasing complexity, and improve my assessment skills. I did get a baby with croup this week and if you have never heard the cough that these little one produce when they have croup it will scare you to death! It is a loud dry bark, and it sounds like they are not going to be able to get their next breath in. I settled mom and dad in the room with this baby and tried to listen to his lungs and he started screaming. A good sign that plenty of air was getting in, he was pink and warm too. So I rushed off to get some Albuterol and set up a blow by nebulizer, and pretty soon he was sounding better and playing with his dad. Then I had to get some IV Decadron in him by mouth. This stuff tastes terrible, I am told, but I did manage to get it in (kind of like getting a cat to swallow a pill) and rewarded him with some nice cold apple juice. We treated him with some humidified air for an hour or so and sent him home with instructions for his parents to use a humidifier or a shower to help him breathe.
I never got a cardiac patient, but I did get quite a bit of experience tracking down the responsible MD for my two admitted patients that were staying with us while we waited for beds to open up. They ended up staying the entire shift and I spent a lot of time paging MD’s to come see them and write some orders so I alleviate their pain while they waited. I learned about tracking down surgeons and advocating for my patients.
Then last night I had a dream that I totally screwed up the computer charting by departing my patients in the computer while they were still here! I was getting yelled at by the clerk and the MD’s to not ever depart patients and I woke up woke up trying to figure out how I was supposed to get them off the tracking board without departing them? And feeling frustrated that I don’t have a good grip on all the logistics of using the patient tracker. Ahhh! Just got a call from the nurse educator that is running our orientation and we are being pulled from the floor to do some more training on the computer tomorrow. I hope to get a better grip by the end of tomorrow. Whew!
The shift started out calm enough, my preceptor and I were taking report on a patient that had been there all night and was being admitted. We were just waiting for a bed. Then at 0755 they rushed him in from triage. He had come in with his mom because he had started vomiting the night before, had acute abdominal pain, was short of breath and he was losing his vision. With that chief complaint and a history of diabetes and pancreatitis, the triage nurse recognized this 30 year old patient was in DKA crisis. The lack of insulin (he wasn’t controlling his diabetes) causes hyperglycemia which leads to osmotic diuresis, dehydration and electrolyte depletion. The free fatty acids are converted to ketone bodies which release hydrogen ions leading to metabolic acidosis. This drop in pH causes increased respirations to try to compensate and the breath smells fruity. This was the case with this patient. His vitals were BP 88/62, HR 146, R28. The teamwork began. The MD was asking him questions while several nurses started working, inserting 2 large bore IV’s , drawing labs and pouring fluids in. I got his finger stick blood glucose level and it was critical high, which means over 500! He was shaky, weak and still vomiting. We got a urine sample, a portable chest xray, and drew some arterial blood for blood gases. He admitted he had been drinking a lot (1-2 pints/day) and his last drink was 9am the previous day. We gave him zofran and 10 units of insulin, someone got an EKG and soon his heart rate shot up to the 180’s and the rhythm started looking whacky, widening and looking like SVT. The MD decided to cardiovert. In a flurry of motion we moved him into the trauma bay got him hooked up to the crash cart administered some versed (5mg, wow) and shocked him with 150 joules. He cried out and jerked on the gurney, and his heart rate dropped to 120. Whew! At this point I was designated as the recorder, my preceptor gave the medications, and a couple of other nurses were managing the IV fluids, and all the other tasks. By this time we had gotten 4 liters of fluid into him, squeezing the bags or hooking them up with the pressure bags used in hemodynamic monitoring. The doc ordered some metoprolol to bring his heart rate down since it was starting to creep up to 145. She ordered 5mg, and asked that only 2.5mg be pushed first as we all watched the monitor to see his heart rate drop. It would be risky to use too much because his blood pressure was so low 104/57 and we didn’t want him to bottom out. His heart rate dropped to 87 in about a minute, it amazed me how fast these medications took effect. We were starting to take a breath here, it was about 0840 and his lab results were in. Blood gases showed pH 7.02, pCO2 <15, pO2 150, HCO3 3, base excess -25.6 Whoah! this guy is really sick. Tox screen came back positive for benzos and opiates, electrolytes were completely out of whack with potassium at 8.3, CO2 at 6, and anion gap at 33. Glucose came in at 966. He was complaining of belly pain so we gave him 4mg of morphine, and his heart rate was creeping up again, so we pushed another 1mg of metoprolol and gave him an albuterol breathing treatment. Usually in DKA the patient has hypokalemia however this patient had hyperkalemia, K level was 8! The MD ordered 1gm of calcium gluconate which quickly overcomes the cardiac toxicity of hyperkalemia, it increases the cardiac muscle tone and force of contractions. More zofran for the nausea and a banana bag to replace electrolytes and vitamins. We had him chew a 325mg aspirin with a few sips of water, I think the doc was worried about a clot forming in his heart through all that fibrillation before the cardioversion. An amp of sodium bicarb (50mEq) IV push slowly, 20mg of kayexalate by mouth, trying desperately to drop his potassium level and raise the pH of his blood. By now it was about 0910 and nurses were all working together to get these meds in him, through the right IV lines avoiding any incompatibilities. Everyone was thinking out loud and checking what they were doing withe each other, the teamwork was amazing to me. I was still busily recording everything with the time that it was happening. Normal saline bag #6 went up, a triple dose of albuterol was given with a nebulizing mask, D5W was hung with 2 more ampules of sodium bicarb. An insulin drip was started at 10 units/ hr, at the same time RT started continuous albuterol 10mg/hr. After all this fluid was poured into him, he needed a catheter to drain his bladder and this was something that struck true fear in this young man. He had just been at death’s door and had his heart shocked back into beating properly, yet he was freaking out about having a catheter put in. Well, my preceptor calmed him, in the midst of the chaos and using lots of lidocaine got the foley in and drained about 200ml of urine. Lab took a sample, and got more blood. Another IV was started in the hand with insulin going in one IV and bicarb in another we needed a third for the banana bag and other meds. His blood pressure was beginning normalize at 122/66 and heart rate at 98. He was needing more pain control so we gave more morphine slowly, titrating to his blood pressure. Then some lasix to get his kidneys to flush through that fluid and RT to draw more ABG’s . Results came back and his pH was up to 7.22, pCO2 22, HCO3 was now 9, and base excess -17. Glucose had dropped to 666, K to 7.1, CO2 to 8 and anion gap to 23. We were going in the right direction. The MD decided to stop the wide open fluids and halt the bicarb drip, now just keeping the banana bag and insulin drip. It was 1030 and we were liking his vitals of BP 137/64, hr 107, R18, O2 sat of 100% and pain 8/10. We started to talk about admission to the ICU. Our patient was beginning to come around and the MD was talking to him about what had just happened. She had a very serious and forceful talk about how close he had come to dying and that he absolutely had to get control of his diabetes and stop drinking. The young man’s mother had been hovering around the outskirts of the activity the whole time quiet tears dropping and looking very frightened. The doctor pointed at her and said to the pt, “you have someone here who loves you and wants you to live, can you at least try to stop drinking and take care of yourself for her?” He started stammering about all the stresses in his life and my preceptor looked at me with a look of “you know he’s not going to change.” We sat down to chart everything from the notes I had been taking. while the other nurses worked on getting him a bed in the ICU. He was not out of the woods yet, for the next couple of days his glucose, insulin, electrolytes would have to be carefully monitored and balanced while monitoring his heart and respiratory function. He was an extremely lucky young man to have been brought in to us when he was and that triage nurse and ED team acted so quickly. As we wheeled him up to the ICU he was beginning to realize what had happened and was thanking us for helping him and saving his life…… I responded with a hand on his arm and looking straight into his eyes “you are welcome, it is our job to save your life, now it is your job to take over.”